Which of the following will the nurse assess in a patient diagnosed with a tension pneumothorax?
1. sucking chest wound
2. dullness of the affected side on percussion
3. muffled heart sounds
4. tracheal deviation from midline
4
Rationale: Tension pneumothorax is characterized by displacement of the trachea from the midline because of a mediastinal shift as a result of increased intrapleural pressure on the affected side. Sucking chest wound is associated with open pneumothorax. Hyperresonance on the affected side is characteristic of tension pneumothorax rather than dullness. A muffled heart sound is not associated with tension pneumothorax; it a sign of cardiac tamponade.
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